MEDICARE: ADVANCED WOUND CARE MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	227059	NY
2	208600000X	Surgery Physician	150869	NY
3	208D00000X	General Practice Physician	156598	NY
4	208600000X	Surgery Physician	087860	NY
5	207R00000X	Internal Medicine Physician	218265	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	07132	OTHER	NY	GHI MEDICARE

General Provider Information

NPI Number	:	1699726315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED WOUND CARE MEDICAL PC

Provider Business Mailing Address
First Line	:	454 AVENUE U
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-4011
Country	:	US
Telephone Number	:	718-382-3400
Fax Number	:	718-382-3420

Provider Business Practice Location Address
First Line	:	454 AVENUE U
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-4011
Country	:	US
Telephone Number	:	718-382-3400
Fax Number	:	718-382-3420

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SERGEI KOCHLATYI
Credential	:	M.D.
Telephone Number	:	718-382-3400

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	10/17/2007

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Directions to “ADVANCED WOUND CARE MEDICAL PC ” Practice Location

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